“A clear conscience is the sure sign of a bad memory.” — Mark Twain
My memory is a blessing and a curse.
On one hand, I can recall nearly every article I’ve written for various media outlets in the past five years, including arcane details of events nobody but me would ever care about. I remember what it felt like to be places, to see things and experience them.
But on the other, I still struggle to remember other things, like the date of my parents’ wedding anniversary or buying coffee or milk for home when it runs out.
I’m confident saying, however, I remember my personal experiences with most, if not all people — both those familiar to me and interactions with strangers.
By virtue of my work I meet a lot of people. I’m not great with names, necessarily, but I remember their faces.
I also remember in unrelenting detail sitting with strangers in some of their most trying or difficult moments — and there’s been more than a handful of those moments in the last seven years.
Maybe I’m just special, but I doubt that. I’m no social worker, so my presence was likely not all that helpful. But I am human.
It’s been difficult for me to accept how former Winnipeg CFS supervisor Diana Verrier can’t remember one thing independently of CFS case files regarding her dealings with Phoenix Sinclair or her family between 2000 and 2004.
A day after Phoenix Sinclair was born, Verrier was there. She sat (or stood, we’ll never know) with Samantha Kematch and Steve Sinclair and gleaned the following information:
Even a cursory glance at the above reports shows Verrier was able to pull intimate details out of two perfect strangers (and Sinclair was noted for being private) prior to her and her partner putting a note on their hospital chart that their baby would be coming into CFS care.
She couldn’t, today, recall any of it — of them — independently of her notes. She can’t remember baby Phoenix — whose travels through the CFS system from the day after she was born always seemed to fail to rate much attention from anybody paid to look out for her.
Nor can Verrier remember signing off on two sepaearte CFS intake reports in early 2004, when Phoenix’s circumstances — do you know anyone named Phoenix? Would you forget them? — appeared to be murky and potentially dangerous and unstable. Maybe she didn’t read them, but that wouldn’t be good practice.
Third time’s the charm, right? By May 11, 2004, Verrier would be confronted again by some familiar names in the “history” section of a report that she signed off on:
Both parents have been involved with child welfare agencies as permanent wards. Samantha became a ward of Cree Nation Child and Family Services in 1993 and Steven a ward of Winnipeg Child and Family Services in 1991. Samantha had one child, when she was seventeen years old who is a permanent ward in care of Cree Nation Child and Family Services. Steven and Samantha had two children together. Phoenix born on April 23, 2000 and apprehended at birth as neither parent was ready or prepared to parent their daughter. In September of 2000 Phoenix was returned to her parents. On April 29, 2001, they had another baby named who went to live with them and Phoenix. died of natural causes related to complications of pneumonia on July 15, 2001 while in the care of Steven shortly after Samantha and Steven separated. Phoenix remained with Steven and the file was closed in March 2002 because Steven did not want any further services from the agency. The file was re-opened on February 28, 2003 due to medical concerns about Phoenix having a foreign object in her nose and was infected. The file was subsequently transferred for ongoing service on June 27, 2003, after Phoenix was apprehended on June 23, 2003. Steven’s ability to parent his daughter had deteriorated to the point of him being under the influence most of the time and subjecting his daughter to inappropriate caregivers. Samantha was also known to be abusing substances and prostituting. Mr. Sinclair requested his child stay in care until he felt strong enough to care for her once again. Phoenix was returned to her father’s care on October 2, 2003. In Jan. /04, Samantha and a friend had a falling out and the friend contacted the Agency to report that Samantha drinks alcohol and smokes “rock” in front of Phoenix. Upon checking, it was determined that the Dad, Steven Sinclair was actually the primary caregiver since Phoenix was just a toddler. Samantha made allegations that Steven was drinking and neglecting Phoenix. Steven in turn made the same allegations against Samantha. It was then determined that phoenix was not living with either one of them as dad had privately placed her with family friends, Kim and Rohan Stevenson, while he got his life in order. As this appeared to be an acceptable arrangement, no further action was taken at the time, however, it was noted in the worker’s recording that Phoenix would be at risk if the situation changed and she was in he care of either parent.
(The bolded sections represent things Verrier, as worker and later, supervisor, would have experienced first hand or read about the case in at least three different files she signed over the years.)
Based on the foregoing, Debbie De Gale, who worked under Verrier, dug a little deeper:
(Source) called to report that Samantha has brought in a letter from her lawyer claiming that she has been caring for Phoenix since Nov. /03 and requested that she be provided financial assistance for phoenix. (Source) stated that the father, Steven Sinclair, has been receiving assistance for Phoenix however, he has been giving it to family friends, Kim and Rohan Stevenson.
was concerned about Phoenix being in her mother’s care, as it was understanding from the previous CFS worker that she would be at risk in either her mother or father’s care. Upon checking CFSIS, this worker was able to -confirm this to be true, provided updated demographic information on all concerned. This worker advised that I will look into this matter and get back to (source)
P/c to Kim and Rohan Stevenson. The person that answered the phone stating that I had the wrong phone number.
P/c to Steven. The phone number has been disconnected.
P/c to Samantha. She claimed that she has been caring for Phoenix since last November. This worker asked her how that came to be since, just in Feb. , phoenix had been privately placed with Kim and Rohan Stevenson. Samantha claimed that it was in fact her, who had placed Phoenix with the Stevenson and not Steven. This worker asked her how long Phoenix had been staying with the Stevensons. Samantha stated that Phoenix had been at the Stevenson’s for a month. This worker asked her why she would put Phoenix to stay with the Stevensons for that length of time, especially given the fact that she had only come back into her care recently (according to Samantha). Samantha then appeared to be at a loss for words, then suddenly she uttered a profanity and hung up the phone on this worker.
Despite this combined with the history and warning signs, Verrier ultimately saw the case as non-urgent, and assessed it as a 2-day follow up instead of one as De Gale had recommended. She described the history as laid out by De Gale above as being “typical” of many others which came across desks in the agency,
We can question that judgement (nobody from CFS saw Kematch until July, anyways), but the real question to me is: how is it remotely possible Verrier doesn’t remember these people at all?
Phoenix, Samantha, Steven: those three names linked together in multiple CFS case files over and over and over again over the years — some of them files she would have read and approved multiple times.
I can’t speak for anyone else, but to me, they — and others wrapped up in their sad, sad story — have become unforgettable.
But it appears to many in CFS who handled the case, including Verrier — who no longer works in child-protection or in Manitoba — they — especially Phoenix — weren’t even worth a second thought.
“One of the great mistakes is to judge policies and programs by their intentions rather than their results.” — Milton Friedman
A few weeks back, prior to the resumption of testimony in the Phoenix Sinclair inquiry, the University of Manitoba’s law school held a morning-long public session on public inquiries and their genesis, largely looking at the Sophonow inquiry held many years ago.
Among the four speakers was former deputy Attorney General Bruce MacFarlane.
As I’ve been pondering the inquiry at length, an off-hand comment MacFarlane made keeps coming back to me.
The thing about public inquiries when you’re in government, MacFarlane said, is you never know what you’re going to get.
His words resonate today, because in the drab downtown Winnipeg convention room where Ted Hughes presides over the increasingly contentious and costly proceedings into the role CFS played in Phoenix’s life up until shortly before her 2005 murder, we’re hearing things which, seen in the right light, could shake our Manitoba reality to its core.
And that may not be a bad thing — in fact, this examination of an exceedingly secretive system might ultimately be just what the ER doctor ordered.
But I suspect confronting what needs to be confronted will be anything but easy.
Let’s start with a fairly well-accepted premise about political power and its legitimacy: A government and the systems it uses to exercise its power (policing, taxation and, yes, child-protection for example) are essentially rendered toothless and ineffective if the citizens those systems serve don’t ‘buy into’ them and accept their actions as proper, justifiable and fair.
(To put it more concretely, even the most garden variety city cop reporter will tell you the ‘f**k the police, f**k the courts’ sentiment in Manitoba is not only prevalent but has grown considerably in the last 20 years. Disrespect for police authority and the justice system is high.)
So, let’s recap just a few salient truths we’ve heard so far about Phoenix and her circumstances, and some of the circumstances of CFS from 2000-2004.
Mom and dad, both young and disadvantaged, were each products of the CFS system.
Phoenix was taken into the custody of CFS same child-welfare system at birth.
Dad was considered a “passive resistant” CFS client who wanted to raise Phoenix himself in order to spare her his own childhood experiences of the system.
When dad was offered CFS services in a time of heavy grief, he rejected them for ones he could access from and in his own community.
The CFS system set rules and goals (case plans) for her parents to reclaim Phoenix, but didn’t follow them to the letter.
CFS committed itself to following up with the family, but couldn’t seem to do it in a uniform or consistent manner.
There was confusion of whether the CFS client was Phoenix, her mom, her dad, both or all three at the same time.
The family lived in a severely challenged community where the need for CFS services was always stretched thin.
The personal ‘values’ workers brought to cases directly influenced important aspects of it, including assessments of risk children faced.
Any actions taken by the CFS system’s actors (largely based on presenting circumstances) were hemmed in by legislation requiring that families and kids were to be dealt with in the “least intrusive” manner possible.
CFS agents — namely social workers — were rebuffed, misdirected or outright lied to in many of their efforts to look out for Phoenix when she was not in care (though at the same time, CFS appeared to do little to verify much of the information it was receiving.)
We could take apart and debate and analyze each and every one of the above.
But for today, anyways, lets just start by looking at the concept of ‘values.’
Consider his clearly stated perspective from his past brushes with the system:
“I was coming from a marginalized group of society: low income, partying lifestyle, general distrust of police and the establishment. … “I had no positive experience with police in my youth certainly, or with CFS. I had only known CFS taking children away. Not fixing families only breaking them.”
Also consider another example, the mistrust and resistance to the agency implied in Steve Sinclair’s statement to social worker Laura Forrest after she came knocking on his door in early 2003. He refused to tell her where Phoenix was.
“Then she would have went down there and got up all in their face. I knew she was safe. That’s all that mattered to me. They would have made a different judgment call in their eyes, right?”
“We’ll see about that,” was Sinclair’s resistant reply to Forrest when she told him she’d return and had to see the little girl.
What the above directly implies is the values and work the CFS system performs clashed with those of its clients. Not all of them, for sure, but likely many.
Also interesting is how in Stephenson’s case, CFS and police are linked as being similar entities — as illegitimate actors of the state whose interference is perceived as an intrusive threat and not a benefit, based on past experiences.
But the quandary is very clear: What is CFS to do if the heart of its work — the children and families it’s mandated to serve — don’t believe in what you’re doing and don’t support your right to do it?
How does the system, looking forward, get past the entrenched ‘us versus them’ mentality? Was this also a goal of the devolution process?
It’s a fundamental, if not foundational question. One Hughes will have to investigate if he’s going to recommend realistic ways to better protect children.
In Phoenix’s lifetime anyways, CFS clearly appeared to be a mess.
And today, we’re told the need for CFS has grown, not abated.
The government — where the buck ultimately stops regardless of the bureaucratic CFS authorities system it uses to deflect that reality — has and will likely continue to throw millions of dollars, discretion-regulating technology and staffers at the system.
That ‘solution’ will continue, I suspect, until the point we’re willing to do what may seem impossible: Confront our issues and prejudices, settle long-standing scores we have with each other and move past them already. Find a better way.
But to reiterate where we started off: We don’t know what we’re gonna get.
The death of any child, no matter the circumstances is horrible, and to see one murdered, simply unspeakable and intolerable. We can all agree to that.
From that baseline, we have our work cut out for us.
That’s clear, and will become even more so in the hard days ahead.
And for once, today there appeared to be more than a single public observer taking in what’s likely to become the most expensive (and I’d contend, expansive) public examination of a huge and hush-hush government department in Manitoba history.
Despite the anticipation, Steve Sinclair’s testimony at the inquiry into the role Child and Family Services played in his daughter’s short life didn’t inch us any closer to discovering anything truly on point.
Let me be clear: As previously stated, I have lot of respect for Mr. Sinclair. I feel horribly for him and his loss(es).
The grief he must deal with I can’t pretend to imagine. And I would never, ever, begrudge him a venue to say what’s on his mind as it relates to Phoenix. Ever.
“I appreciate the chance to speak,” he told Commissioner Hughes after being dismissed from the witness stand.
I have no doubt he did. And, for the record, I’m glad he did.
But I’m wracking my brain to figure how what Sinclair told us fits into the picture the first phase of this inquiry is supposed to be painting.
That is: to help us unravel the actions and inactions of CFS as they related to Phoenix before she wound up back in her mother’s care, and somehow wound up lonely, abused and murdered on a tiny Manitoba reserve.
It was interesting to note Sinclair’s observations about Samantha Kematch, how she didn’t want to talk about her first-born son and he didn’t want to pry. It was heartbreaking to hear his recollections of Phoenix as he visited with her in a CFS office as a baby and what she was like in his home at age three. It was concerning to see the effect his second daughter’s death clearly had on him.
I did find it extremely important Sinclair discussed what happened and his apparent confusion when he agreed to let Kematch take Phoenix for a few hours only to never see her again, and to also get a little more clarification on how Phoenix wound up at HSC with a foreign object in her nose in early 2003.
And it was also interesting to hear from Sinclair’s own lips the underpinnings of why CFS concluded he was a “passive resistant” client.
But again, such things appeared to me to be ‘story’ when it’s ‘process’ we’re jousting with: the ‘story’ of a gigantic government child-protection system and how it operates.
Sinclair’s first-person version of events and clarifications of circumstances weren’t written up in any CFS report we’ve seen yet — a report to be used as information by which agency decisions were made during his daughter’s lifetime.
We should be focusing here on the systemic problems with Manitoba child-welfare and ‘process’ as they related to Phoenix’s case at the time, looking at the internal decisions CFS agents made based on the information CFS gathered.
As far as I can see today, Sinclair’s testimony — at this stage of the inquiry — didn’t help us answer or put into any much greater context the serious questions which have surfaced.
A scant few of those questions, simply rattled off from the top of my head, might include:
Why did Winnipeg CFS allow Kematch and Sinclair to have Phoenix back prior to her completing a psychological assessment/evaluation deemed vital at the time Phoenix was born?
Is it enough for a social worker and her supervisor to say because a child — one who had once been in CFS care — has been seen quickly by an ER doctor, that that constitutes in any way a safety assessment as to what risk she may be in?
Why was Sinclair allowed by CFS to unconditionally reclaim Phoenix seven weeks before her court-sanctioned period in custody (it was the shortest order the law allowed) ended? Allowed to take her back despite he took no programming to deal with the drinking issue that was deemed so risky for Phoenix she needed to be brought into care?
When, in early 2004, it appeared Sinclair (described by CFS as her ‘primary caregiver’) was totally AWOL and Kematch was mysteriously caring for Phoenix at times, was the little girl allowed to live at her godparents without any long-term state-sanctioned plan for her care and well-being? And no legal guardianship order being in effect?
Why was one worker’s comprehensive risk assessment of the family’s case simply tossed out by another worker to start “fresh?”
Where are all the supervisory notes?
What we’re trying to answer here, I thought, was, how did the provincial child-welfare system — not her dad — fail Phoenix?
I don’t recall Sinclair being asked many questions about what he’d have liked to see CFS do in his case, what solutions he might have as a person involved in a system he likely loathes. In fact, I can’t say I heard many tough questions asked of him at all.
His evidence may have been more helpful in the inquiry’s upcoming third phase, which will look broadly at societal conditions such as poverty; how they may have factored into Phoenix’s death.
Maybe I’m just not seeing it — but I don’t see how Sinclair’s evidence put us any closer to what we’re trying to get at today.
If you can help me out, fire away in the comment section.
“People can’t make choices they didn’t know they had” — wise Manitoba lawyer
I’ve never met Steve Sinclair. I don’t really know the first thing about him.
But over the past few weeks I’ve had to really watch myself — to guard against the conceit that I somehow do.
Ever since testimony really got underway in the Phoenix Sinclair inquiry a few weeks back, I’ve spent more than a few moments pondering her dad.
To be more specific: I’ve been trying to put my head around what it might be like to see intimate personal details about your troubled life through your childhood and young adulthood be cast out into the street for all to bear witness to day after day after day for all to see.
Manitoba is undertaking an inquiry into Phoenix Sinclair’s short existence, for sure — but in many instances it’s also appeared to have taken on the shape and form of a microscopic examination of Steve’s life as well.
I suppose it’s unavoidable. No. That’s just wrong. It is unavoidable.
It would be simply impossible to get to the bottom of what actions CFS took (or, as it’s becoming more clear didn’t take but maybe could have) during Phoenix’s all-too-short lifetime without proffering explicit details about Sinclair’s life and the circumstances which informed it before and after after his daughter was born.
We’ve been given a lot of information about Sinclair’s troubled past and, it must be said, reputed failings as a father. But those observations have largely all been filtered through the sieve of the minds, priorities and discretionary note-taking and observations of social workers and other CFS officials.
Sinclair drank heavily at times, we’re told. Couldn’t stay sober enough to hang on to Phoenix at one point. Appears to have abandoned her and vanished at another. Came from a background of CFS involvement and family abuse. Was on welfare. Didn’t seem to work.
And, it perhaps goes without saying: At least one time in his life Sinclair displayed horrible taste in whom he became romantically involved with.
But lost in the bureaucratic morass of case summaries, field visits and wrangling over lost notes and the imprecise departmental distinctions between safety and risk, there’s clearly another side to Sinclair.
To put it simply: It’s pretty apparent he tried.
Tried to play by the CFS rules to be a good dad despite a gloomy history of involvement with CFS agencies, its agents and foster homes over his lifetime. Tried to be a dad to his daughter in circumstances most would find beyond trying or manageable.
And likely, although it hasn’t been explicitly stated, seems to have tried to overcome his reputation as a “passive resistant” CFS client.
Hell, his real name is Nelson Draper Steve Sinclair, but consistently CFS workers refer and referred to him as “Steven.” [I’ve done this too in two separate reports and I felt horribly.]
Think about how remarkable Sinclair’s efforts are, really. Think of them in the context of the sickening and judgemental tenor of our society’s (mostly anonymous) gum-flapping about “welfare bums” and “natives” abusing the social-welfare system. Not to mention within the often-mentioned reality that aboriginal communities need fathers to step up. (More: Here).
More kids equals more free government assistance cash. Blah, blah, blah. (God, how our criticisms have become dismally uninformed and trite.)
I’m asking you to regard Sinclair within the context of the inquiry’s evidence so far.
That being: Sinclair as a young aboriginal man who clearly had little to no material wealth or grand future prospects and who didn’t just throw up his hands when his daughter was born and seized by CFS.
He agreed to work with the agency. And he did. As far as we’ve been made aware, between April 2000 and at least February 2001, he met all the demands placed on him. He, Kematch and Phoenix appeared to have a stable home life.
Then came April 2001 and the birth of Echo, his second daughter. It’s impossible to really know whether it was a lack of CFS diligence which allowed he and Kematch to leave the hospital without any CFS intervention (It was Delores Chief-Abigosis’s file at this point) or if it was because there were no child-protection concerns for Echo at the time.
Nevertheless, it’s pretty clear by now who was viewed as the real risk to Phoenix, and it wasn’t Sinclair.
When Kematch left their home a few weeks later with Echo in tow, it was Steve who picked up the ball and ran with it.
A couple of days later Kematch brought Echo back in a filthy state , leaving Sinclair a single dad who cared for both the kids, ostensibly with some help from friends. When Chief-Abigosis visited with him in July 2001, Steve was the person feeding Echo, holding her.
He and his sisters organized a sit-down with a worker this month to lay bare their concerns about what was going on in Steve’s life.
Then, Echo died suddenly of a respiratory infection, through no fault of Sinclair’s. Police quickly determined there was no foul play involved.
In the wake of Echo’s death, CFS says they offered Steve services on a voluntary basis. We don’t know yet why he rejected them — but it’s clear he was still working with community resources of some kind. I’ve never experienced such a great loss, so I won’t presume to get into Sinclair’s head as to what he was going through.
Months passed without apparent incident, except for Phoenix being brought to hospital in early 2003 with a thing in her nose, which may have been there for months. Worker Laura Forrest met with him soon after — at the same home he had lived in for about two years at this point.
She described Sinclair as “foul but sober” in her dealings with him. Insisting she’d return to see Phoenix, his reply, according to her, was “we’ll see about that.” How to interpret that properly? It’s impossible to know, really.
Phoenix would be be apprehended again June 22, 2003 after Sinclair apparently couldn’t get his act together enough to satisfy pairs of CFS workers he was able to care for Phoenix. There was no evidence whatsoever she was being abused in any way. Possible neglect was the real worry. Possible.
Phoenix was described emphatically by workers who sat with her in her the Place Louis Riel hotel room emergency placement as “well behaved,” as well as potty trained — so there had to be some parenting happening, some measure of honest care, in her life.
And although Kematch resurfaced at this point, making overtures to parent Phoenix, it was Sinclair who turned up in court on Aug. 13, 2003 with worker Stan Williams to say he wanted to resume parenting once he got things together.
Williams isn’t alive today to share his version and impressions of Steve, but through his boss, we learned he became a fierce advocate for the 21-year-old dad, believed in him to the point he’d basically — for right or wrong — convince his boss to get CFS to hand Phoenix back to Sinclair unconditionally on Oct. 2, 2003.
From there, it’s hard to say what the hell happened.
We do know CFS believes Phoenix somehow wound up in the care of Kematch for a while before she then mysteriously made her way to the safety of foster parent Rohan Stephenson, who, along with his ex, Kim, were good and trusted friends of Sinclair’s — people he (and CFS) trusted to care for Phoenix.
Had Sinclair gone off the rails and ditched out on being a dad?
He was hard to find — but it’s clear that when a worker finally spoke with him on Feb. 5, 2004, he agreed the best thing for Phoenix was for her to stay with the Stephensons as an unofficial place of safety. In a sense — that action was his doing right by Phoenix.
And that’s where we’re left off for now. Yes, there are gaps. Yes, there are some questionable decisions Sinclair made.
But he didn’t ever, ever appear to hurt his little girl — and he certainly didn’t murder her. Neglect her at times, perhaps, sure.
Wednesday morning, Sinclair is scheduled to take the witness stand.
We’re going to hear first-hand his side of the story. Why he chose to act as he did.
But to me, the inquiry — the most expensive such public proceeding in Manitoba’s history, and probably the most contentious — wouldn’t be possible without some major buy-in from Steve Sinclair, some continued effort on his part to see some kind of answers to what sounds like an easy question:
What the hell happened here?
Even in light of Phoenix’s death, Sinclair’s participation in the inquiry, to me, shows he was a father who cared.
And that’s a lot more than many, many other kids in Manitoba have.
We’re not in a position to judge Steve Sinclair.
People can’t make choices they didn’t know they had.
Another illuminating moment today at the inquiry into how Phoenix Sinclair fell through the cracks of our provincial child-protection system.
It had to do with the information social workers rely on when assessing the urgency — some may describe that as ‘risk’ — when responding to a case; specifically, how soon Phoenix needed the system’s attention.
I’ve written before about social worker Laura Forrest being lauded in at least one internal review after Phoenix’s death (as well as by CFS employees on the witness stand) regarding her June 2003 case summary, which finally put together all available information about the case and the concerning backgrounds of her parents.
Forrest saw that, all things considered, her case was high risk and that CFS couldn’t go away from her life.
Her risk assessment would ultimately be deemed an “opinion” by subsequent workers and tossed aside to allow Steve Sinclair a fresh start with CFS and a new worker after Phoenix was taken from him in June 2003.
By the time Sinclair regained custody of her on Oct. 2, 2003, colleague and case worker Stan Williams’s closing summary of the case looked starkly different than Forrest’s.
I won’t reprint Forrest’s in its entirety, it’s pages long and extremely deep (it can be found here) Below, however, is the final, but still lengthy section in her ‘Statement of Risk.’
“Steven and Samantha have clearly indicated their mistrust and unwillingness to be involved with a child welfare agency however they have not demonstrated a capacity and commitment to ensure their child’s wellbeing enough for the agency not to be involved. Unfortunately. because of their past involvement as wards of a child welfare agency they arc not receptive to services from the agency and they deny or minimize any Issues presented in an effort to keep the agency away from them. They would do anything, or nothing, to keep the agency at bay. It is this worker’s opinion that it is this attitude and disregard for the agency that has probably resulted in this agency’s previous termination of services, and not a lack of child welfare issues, If one looks back in previous recording the identified and unresolved problems are still very much present in the family’s current situation. The problems haven’t gone away, and now neither can the agency. The obvious struggle in commitment, questionable parenting capacity, along with an unstable home environment and substance abuse lssue(s), and lack of positive support system all lend to a situation that poses a high level of risk to this child, for maltreatment and / or placement in agency care. Phoenix Is in agency care no(w) and it would probably not be in her best interests to be returned to either parent at this time or until they can show something to indicate that they can and will be more responsible and protective other.”
Now, for the sake of contrast, here’s Stan Williams’s final word on the case, under the “Unresolved Problems‘ section. It was authored around the time Phoenix was allowed by CFS to go back to dad unconditionally without having taken any programming for his alcohol problem.
“Mr. Sinclair requested his child stay in care until he felt strong enough to care for her again. He has had his time out and will parent Phoenix starting Oct. 2, 2003. He has done no programming and as such is prone to an unhealthy way of managing stresses in his life. He is aware of the need to arrange for appropriate alternative caregivers when he feels the need for a break or time out for respite.”
It goes without saying there’s a massive difference between the tone, content and, I submit — the intent of the two statements, prepared mere months apart by different social workers with apparently different mindsets.
But the net effect of this apparent discretionary revisionism was revealed today in relation to how another social worker, Lisa Conlin (and, her supervisor) started off their investigation into subsequent allegations Phoenix could be at risk in January 2004.
Conlin says she didn’t or can’t remember looking at past Kematch or Sinclair files the agency had on record when the file came to her on Jan. 20, 2004.
Did you look up either of the parents’ information on CFSIS (the internal computer system)?, commission counsel Sherri Walsh asked.
“Well, I believe I for sure would have looked at his (inaudible) that was open to me,” she said.
At Steve Sinclair’s?
“Steve Sinclair’s. That would be my typical practice,” she said.
And what would you have looked at? What information would you have looked at?
“The last closing summary,” Conlin replied.
So in this case, that’s the one at November 2003 (The Williams closing summary, referenced above.)? What about the one immediately before that — still in Mr. Sinclair’s file, from March 2002 — would you have looked at that one as well?
“I don’t specifically recall that one.”
You don’t recall looking at that one?
Was it your practice, typically, just to look at the most recent file closing?
“Typically, because, what happens is the latest worker would have summarized already the previous closing summary — so you get a recent summary in the most recent closing. Just like when the intake initially comes to me from the Crisis Response Unit, there’s a summary … in there.” (To be fair, there was also a short ‘cut and pasted’ recounting of the family’s history and CFS involvement in that summary).
So if we look at the summary you would have reviewed … (Nov. 13, 2003, the Williams summary) under the heading ‘unresolved problems’ (Walsh reads the section, listed above, aloud to her)
“I don’t recall exactly when I looked at this,” she says. “It’s just something (as a matter of practice) I would have done,” said Conlin.
As you can clearly see, there’s a huge discrepancy in content and tone between the Forrest and Williams case summaries.
One (Forrest’s) darkly and deeply warns of the risk Phoenix was in and — by my reading — essentially urges the agency to stay involved in the little girl’s life.
The other, Williams’ laconic five-sentence-long summary essentially — to me — suggests almost the polar opposite – that the agency take a hands-off approach for the young dad who just needed a time out from parenting. (as if that wasn’t a warning sign in itself).
Problem is, when problems crept up again a few months later, Conlin, a busy social worker handling short-term child-protection intervention calls in the city’s most challenged area — likely only had so much time to delve into the file. Who knows. Maybe she just didn’t see the need to look further given the presenting child-welfare issues in the case she was to look into.
But it’s clear to me, at least, that it’s certainly more likely a social worker’s guard would have been raised significantly more if Forrest’s case summary had remained the one at the top of the pile.
“This is an inquiry and an inquiry we must now proceed to do with all possible diligence.” Ted Hughes
To describe as ‘heroic’ any of the witnesses who have testified at the Phoenix Sinclair inquiry so far could appear as faulty as some of the decision-making employees of Child and Family Services made over the duration of the little girl’s involvement with the child-welfare system circa 2001-2004 — the period which we’ve been learning about so far.
But it’s my opinion if there’s any one of them deserving of a good measure of our respect today, it’s Heather Edinborough, for the simple reason that her candour has clearly put us closer to what we’re supposed to be after here: The truth of how a little child fell off the radar of Manitoba CFS and suffered horribly because of it.
Before I get to why I believe Edinborough should be lauded (despite her admissions that several things in the Sinclair-Phoenix case weren’t done at all properly under her watch as a Winnipeg CFS Supervisor in 2003) there’s something I need to get off my chest about the inquiry and the role of the media.
And this is not a critique. Just an observation.
From this reporter’s perspective, the proceedings haven’t in any way been easy to cover.
The media, by and large, makes its hay by boiling things down into simple ‘opposition’ narratives reinforced by time-worn themes.
Good versus evil. Right battles wrong. David tackles Goliath.
Acknowledging this helps explain the overuse of the word ‘story/ies’ to describe the product readers and viewers consume and — in another sense — the newsgathering process itself.
“How’s that story coming, Turner?,” the editor barked.
Complexity is generally eschewed for the sake of the “story.”
But in the case of this inquiry, ‘boiling down’ or trying to make the information fit a story arc just won’t work.
I can’t see how it can happen and grow the public’s understanding of the machinations of our child-welfare system.
I am willing to accept my inability to see this could just speak to my skills as a journalist.
But if we’re going to get at the truth here and be able to communicate it meaningfully to shine light on Manitoba’s CFS system, it will only be done with the realization there is no easy 140-character narrative to do it through.
To unravel how Phoenix fell through the cracks and prevent other kids from the same fate, we’re going to have to wade far out into complexity and nuance; fully be OK with the undeniable fact it wasn’t ONE thing (say, incompetence) that led us to the sad place we’re at today.
Instead, it’s a whole host of circumstances at play inside an unwieldy and bureaucratic machine operating with a somewhat (it seems to me) contradictory mandate: protecting kids and trying to fix/reunite unhealthy families.
Couple the contradiction with the fact that how the mandate is fulfilled appears to involve huge amounts of discretion by various CFS actors, some performing the front line work (who don’t have standardized training) — it’s easy to see how things could go wrong.
But one of the things I was reminded of by Heather Edinborough’s testimony on Friday is this: The vast majority of people doing CFS work aren’t bad people. They’re people who believe they can make a positive difference in people’s lives despite inordinate and complex challenges coming at them each day, every day.
In summer 2003, Edinborough, a Winnipeg CFS supervisor and social worker Stan Williams set about trying to do the right thing for Phoenix’s dad Steve Sinclair using the tools of the system they had to work with.
A natural virtue of that, as I see the underlying reasoning, is if they reached Sinclair — gave him a “fresh start” — got him on a positive path, then the system’s ultimate goal of protecting Phoenix in the long-term could be the happy consequence, along with their reunification.
Williams isn’t alive today to answer to the commission for his role in the case, of what he and Sinclair discussed that so convinced him Phoenix could be returned after a “time out” without the young single dad doing the counselling Williams once clearly believed was vital. Or return her without a conditional agreement as had happened two years prior after the girl was first seized and returned.
It’s clear, to me, anyways, Williams understated concerns about Sinclair’s ability to parent when approaching Edinborough to sign off on his work and close the case.
We’ll never know why that is.
We do know Edinborough “winced” when reading his case closing summary at the time and says she continues to do so to this day.
She signed it anyways. Approved his work.
“The work wasn’t very good. It wasn’t enough. It wasn’t good enough,” she testified Friday.
Note how Edinborough didn’t say: “The work didn’t meet standards” or, “I don’t recall.”
The work Williams did was poor. Period. She signed off on it and I shouldn’t have. Period. No prevarication from her — just ownership.
So, then there’s one thing at play. The work was not good enough.
Then there’s the issue of the missing supervisory notes. A mystery.
And multiple issues about the lack of documentation in the social workers’ work.
And then the issue of how a child-protection case can go from one experienced worker seeing it as a “high-risk” situation, to another viewing it as low-risk within a matter of days when the only thing known that had changed was the child being seized.
The list of lacunae goes on and on.
Each problem carries with it a wealth of underpinning issues behind why.
These include, but aren’t limited to: workload/caseload demands, the fact social workers aren’t robots. Some of them weren’t up to the tasks. The fact new devolution policy was likely causing headaches and uncertainly in terms of who was going to be doing what and when and how and where. The fact the clients — truly the heart of the work — each presented different problems which needed to be considered and weighed.
RISK and SAFETY
But Edinborough, to her credit and our benefit, shed a lot of light on what I see so far as the number one systemic issue which led to little Phoenix’s calamity.
(Setting aside for a second she had a despicable mother who kept house with a vile boyfriend).
It’s how CFS, again — in Phoenix’s lifetime — handled the concepts of “risk,” “safety” and assessment of potential future harm to a child.
(Having looked into the topic, one could have a public inquiry based just on this one general issue alone, I suspect).
Edinborough, like most other material witnesses, was asked to comment on the findings of internal and independent reviews conducted after Phoenix’s death was discovered.
One of them, a file review by Rhonda Warren, outlines succinctly the most confounding internal problem CFS likely faced. Here’s the excerpt.
Statements of risk change from low to high without any change in circumstance. Statements of Safety are referred to as Statements of Risk. A family situation may be high risk even if on any given day the child is deemed to be safe. Unfortunately in this case `low safety assessments’ were deemed to be `low risk assessments’ which were not the case. This continuous error resulted in this case being closed numerous times without adequate intervention by the Agency. An Intake worker clearly articulated this problem in an assessment done in June 2003 (note: right before Edinborough took over the file). She states:
“It is this worker’s opinion that it is this attitude [resistance] and disregard for the Agency that has probably resulted in this Agency’s previous termination of services, and not lack of child welfare issues. If one looks back in previous recording the identified and unresolved problems are still very much present in the family’s current situation. The problems haven’t gone away, and now neither can the Agency. The obvious struggle in commitment, questionable parenting capacity, along with an unstable home environment and substance abuse issues, and lack of positive support system all lend to a situation that poses a high level of risk to this child, for maltreatment and or placement in Agency care.” (This is from Laura Forrest’s file transfer on July 27, 2003 — Commission lawyer Sherri Walsh didn’t read this out directly to Edinborough as this section was discussed earlier in the day).
Unfortunately this statement was ultimately ignored once the case was transferred for ongoing service. Based on this case review it is apparent that Risk Assessment is not universally understood by Agency staff. (emphasis in original).
Here’s the verbatim response from Edinborough after Walsh read most of the above to her.
“I think that most of this section is absolutely accurate. I think — I hope the writer of this report knows a lot more about standards and safety, the difference between safety assessments and risk assessments than I certainly did at that time.
However, I think she’s hit the core of what the problem has been, and that’s because risk assessments in particular are based on people’s opinions which are formed by — as I said before — bringing our own values and experience, experience with that client that the risk of it changing every time a worker was assigned was there.
That risk — the risk of the risk changing that’s accurate — and it happened.
I think with the tool we discussed (more on this below), I think that’s less liable for that to happen … the substance of what she says here is absolutely accurate.
Walsh: You recall earlier, a very long time ago this morning, I asked you when an assessment was done as to Phoenix’s safety when she was returned to her father, if there was any concern given to long-term risk of harm at that point.
Edinborough: “Right.” (She earlier testified she wouldn’t expect a social worker in 2003 to speak to the long-term prospect of harm a child may face given all the circumstances learned during a worker’s time with a case — see below).
And that’s what I meant — was were you considering at the moment she was being returned she was safe only? Or were you also considering what her future risk of harm or well-being would be?
Certainly her current safety, the potential of risk is certainly a consideration and factor into that. If we have indeed addressed some of the problems and believe the child is safe enough to return home, the belief is if those changes that were made persist, that the long-term safety of the child, or the long-term lack of risk to the child would continue to exist as well.
Edinborough earlier testified on Friday: A file came to her office from the CFS intake unit with an assessment of risk on it. It was intake came up with an assessment of what the risk was.
When she got the file, her office would pay attention to that risk statement, but her expectation was risk would be assessed by the assigned social worker as he/she worked with the client. “Risk assessment continues to evolve based on the work that occurs.” She said at the time, in ’03, she wouldn’t have seen an intake “safety assessment” as being different from the concept of “risk assessment.” From intake, risk spoke to whatever the “risk might be. It varied.”
For her now (she recently retired from a high-up position at Michif CFS/Metis CFS authority), she says a safety assessment comes out of the (intake computer system) and “risk” is about the potential for future harm.
In 2003, she says the timeframe of the risk assessment looked at the period by which the file was open — “the goal always would be to reduce risk over the life of the file, over the life of the time the worker worked with the family.”
If a file arrived on her desk with high-medium risk, the goal was to reduce/eliminate risk. Harm could be abuse or neglect of a child, she agreed.
For the time your family service worker had the file, did you expect they would consider the child’s long-term well being, govern their actions based on that?
Edinborough: “Depending perhaps on the age of the child, I wouldn’t expect a worker to say everything’s fine now and the infant was safe and then be able to predict – I don’t know how long term … They wouldn’t be able to predict how that child would do at school or what kind of teenager they’d be, so I’m not sure what you…
So then the actions taken on the file would not take into consideration those longer-term eventualities?
Edinborough: No, I wouldn’t expect a social worker to speak to that.
So then, given this realization, what’s changed to address this critical issue?
During the proceedings, a few witnesses have mentioned something called “structured decision making” or the “SDM tool.”
However, Instead of it being a concept, SDM is a computer-based case-management tool used to measure risk not only at the intake level, but also looks at likelihood of future harm for a child.
How it all works exactly will be discussed at length during the inquiries 2nd phase in the new year.
Some child-protection agencies in the U.S. have been using SDM now for many years.
In 2002, North Carolina’s Department of Health and Human Services, Division of Social Services (the Division), implemented an SDM® case management system to assist child protection workers in making decisions at critical points during a child protective services (CPS) case …
The primary goal of the SDM case management system in CPS is to reduce the subsequent maltreatment of children in families in which an abuse or neglect incident has occurred. The underlying logic of the approach is that the most effective way to reduce child maltreatment is to accurately identify high risk families, prioritize them for agency service intervention, and deliver effective services appropriate to their needs.
The objective of a structured approach to case management is to increase the consistency, validity, utility, and equity of decisions at every agency level. Workers complete research- informed assessments at key decision points of a child protection case, and each assessment is designed to inform the relevant decision. This helps ensure that all workers consider the same information when making a decision and that assessment findings inform determinations of service delivery and prioritization. If assessment information is accessible, agency managers can use findings in aggregate to profile their clients, determine service needs and availability, and manage operations. These efforts are likely to increase the effectiveness of the child protection system.
A watershed moment came today in the Phoenix Sinclair Inquiry. One I’d been quietly waiting for since testimony really got underway a couple of weeks ago.
A Child and Family Services social worker uttered the single word that — to me, anyways — appears to underscore exactly how Phoenix wound up in the hideous predicament she did.
Its common definition is simple: “The freedom to decide what should be done in a situation.”
I’m beginning to see that discretion, at least as it relates to the evidence we’ve heard so far, figures in several ways in Phoenix’s tragedy on levels both systemic and personal.
And it can’t be forgotten, as a child, Phoenix had none of her own. In a sense, she was but a pawn in the act of everyone else exercising their own professional and personal autonomy, no matter their good intentions.
In terms of how it was broached today, former Winnipeg CFS supervisor Lorna Hanson described how social workers, at least in 2000-2001, had leeway in terms of how and when they reported their handwritten case notes into a case file.
(It maybe need not be said that when it comes to getting at the truth of what happened to Phoenix, notes — and the lack thereof — has become a major concern. More on this another time.)
“There’s some discretion of the social worker” on when notes go into the file, Hanson said. “Workers have to use some of their professional experience and discretion in those types of things.”
If we look closely at the evidence so far, we know there are far, far more examples of discretionary actions in this case. Maybe too many to count.
A small handful, in no particular order, would be (links as I can find them):
The decision by the hospital in April 2001 to allow Echo to return home with Kematch with little intervention despite knowing at least something about the family’s past issues.
The decision by CFS worker Delores Chief-Abigosis to not pursue the family’s case more aggressively in early 2001 after Kematch got snippy with her during the only home visit she did on the file where she notes seeing Phoenix. In fact much of her involvement — or lack thereof — could possibly be put down to discretion, as she has no recall of virtually anything and her notes about working on the case are scant.
The decision by Winnipeg CFS to allow Kematch and Sinclair to take Phoenix home with them prior to Kematch undergoing a psychological evaluation.
The decision by some internal investigators to not interview or consult some of the people involved when reviewing the case after Phoenix’s murder was discovered.
The decision by Karl McKay and Kematch to abuse, torture and murder an innocent little girl and callously bury her near a dump. No one can say they lacked the discretion to not do this.
Virtually every social worker’s case notations on the case are a matter of discretion. ‘Note this, not that.’ ‘This is important information to document.’ ‘That’s not.’
The list goes on and on in this case, and would also extend all the way up the ladder to government decision making.
People, professional people, paid to make decisions — in what sounds like awful circumstances — in cases involving children’s lives.
It goes without saying that without discretion, our world would decent into rule-book procedural chaos. Absolutely everything. I get that.
I’m generally okay with the idea that prosecutors and police officers, for example, should be allowed a measure of individual discretion in their different roles of trying to protect the public peace.
But CFS social workers aren’t cops. They aren’t Crowns.
They aren’t sworn or uniformed to protect and serve. Last I heard they labour under no oaths and aren’t even, by and large, registered with an oversight agency as registered nurses are.
That’s despite the fact they work in a clandestine system (words like ‘apprehension’ and ‘report,’ ‘crisis response’ and ‘investigation’ are pivotal CFS terms) which plays a major policing role to safeguard the well-being of our most vulnerable citizens.
Look, I don’t believe for a second that anyone would go through the effort and costs to become a social worker if they had any ill-intent.
But when Hanson testified today she believes that every social worker in the child-welfare system should receive mandated, standardized training, my jaw dropped.
‘That doesn’t already happen?,’ I thought.
It’s my belief — and I’m willing to be called out for being wrong — that when Commissioner Hughes issues his report on Phoenix’s case next fall, he’ll point to ‘discretion’ as a a major issue of why she got away from the system — from all of us — and wound up so horribly killed.
[Addendum: I just realized there was one additional example of ‘discretion’ I failed to mention: It’s incumbent on the government to ensure the social-welfare system is adequately resourced — especially when it comes to the protection of children. While I accept there’s been a number of efforts in recent years to address this, my understanding is more could still be done.]
To say it’s disheartening hearing the evidence that’s coming out at the Phoenix Sinclair Inquiry would be beyond an understatement.
But among the litany of facts painting the picture of major systemic breakdown — a portrait of ignominy becoming clearer each passing day — there are moments of fascinating clarity.
One of them came today, in the testimony of veteran CFS caseworker Laura Forrest, who, like many of her colleagues, was asked towards the end of her time on the stand to comment on the nature of the CFS system in general and improvements which could be made to it to better protect Manitoba kids.
Forrest handled Phoenix’s case for a few months, and despite her failure to physically see and visit the child in following up what was considered to be a low-risk potential maltreatment claim, it was Forrest who finally put together all the available information to determine the little girl’s background equalled nothing less than a high-risk situation.
And her parents’ negative attitude and disregard for CFS and its work was a huge factor in her finding, which a review noted was largely ignored a few weeks after she came to this conclusion.
Fast forward to today, and Forrest is no longer an intake worker with CFS, handling crises and complex cases as they poured in by the bucketsful.
She now works delivering services to families as a case worker — a step removed from the process of initial contact and assessment of cases by CFS. (EDIT: she’s actually doing foster-care placements, but left intake in 2009 to move to a family service position with CFS till recently).
Off the top, Forrest readily admitted her workload was high — if not huge — in her time in intake, and that continued till she left that unit in 2009. By then, several reviews of Phoenix’s case had been done, and changes implemented by officials to try and ensure no similar situation ever happened again.
“My practice was to do the best I could with what I had,” she said.
Forrest says she was never consulted or interviewed about any of the reviews that were done or findings made, something she says she would have liked to have seen happen just because the investigations analyzed her work. It also may have been educational for her, she said.
“What’s the answer to workload issues?,” Commission lawyer Sherri Walsh asked her today — toward the end of Forrest’s lengthy testimony.
She paused a while before speaking.
“I guess, it’s a big answer. Because it’s not as simple as telling a system, ‘these are all these standards you should be following and that will take care of everything. We deal with really complex family situations. And depending on where they’re coming from, lack of community resources, increased issues with respect to addictions, mental health, which makes things much more complicated – families placing their children into care at much more, much higher numbers.
The system can try and change as much as it can sometimes, but if everything else around, in our community is also escalating in terms of their needs and their problems that they’re trying to deal with, I don’t know how we can keep up, to be honest.”
“In my experience — over 20 years — things have changed. It’s not easier to do my job.
Not withstanding changes in the system?
“Yeah. I mean, I think that we all try to do the very best that we can, whether people can believe that or not. We have a lot of hope, we have a lot of belief that people can make changes, that families can make changes. Sometimes I find if I didn’t have those, that would be very very difficult, because sometimes that’s all you have with a family.
So, is very simply one answer to the workload concerns reducing the need? Prevention?
“Well, prevention would be helpful. So if you could look at some prevention programs that could be in place even within [the] system, we had those — we had a couple of them — and they were helpful in terms of dealing with families that had teenagers out of control. But those programs were changed and something else came about as a result of that. So I think that it would be helpful if we found practical interventions that would actually really, adequately meet family needs in a realistic fashion.
We can tell them what we think we need them to do, but if they can’t do it because they don’t have enough food, they don’t — they’re struggling maintaining the three or four or two kids in their home because they’re a single parent and they don’t have a lot of resources — I think we have to be fair and mindful that these are people that are working hard to do the best they can.
We have to come up with better solutions as to what we can offer them for intervention. So that could be helpful — some practical intervention, some more practical and more available resources. I always hope for that and I know other people do. And I know the community resources try as much as they can as well with what they have. But, you know, to say that one system has to make all the change and that will take care of everything and no child will be harmed again — I don’t know if that’s going to happen by just looking at one system.
You say that protecting children can’t just be put on the shoulders of the child-welfare system.
“We have that burden. But it would be helpful if we had other supports and resources. Not for us, but for the families.
We talked about community resources and addressing issues of poverty, employment, education, child care — those are all things that would help, ultimately, with workload?
“Yeah. These are all the things that our families struggle with and we have to try and help them overcome those. Sometimes it’s very difficult.
Was there anything about (Phoenix’s family’s) circumstances, either in terms of their factual circumstances or the nature of services that were being delivered by the agency that stood out in your mind as compared to other families that you were working with?
“This family situation was fairly similar to many families I had dealt with. Whether it was single parent dealing with addictions issues, conflict with the other parent, struggling to manage in child care, relying on other family members. It wasn’t unique in itself. There are certain things about it that make them different but often times I dealt with families that struggled with poverty … parenting … addictions … mental health. It was more common than not.